Evento Ostetrico e Perineo Le lacerazioni perineali

marco soligo

Azienda Ospedaliera

Istituti Clinici di PerfezionamentoOspedale di rilievo nazionale e di alta specializzazione convenzionato con l’Università degli Studi di Milano

Ospedale dei Bambini V. BuzziDipartimento della Donna, Mamma e Neonato

Direttore prof. Enrico Ferrazzi

Evento Ostetrico e Perineo Le lacerazioni perineali

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22 articles, 651.934 women included

severe perineal lacerations (III°-IV °) 15.366 (2.4%)

from 0,3% in Tel Aviv to 6,8 in USA

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severe perineal lacerations (III°-IV °)

on 967 consecutive women

III° 3 (2.6%)

IV 0

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14Evento Ostetrico e Perineo

Le lacerazioni perineali

•Lacerazioni PerinealiLacerazioni Perineali

•Lacerazioni VaginaliLacerazioni Vaginali

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Classification of Perineal LacerationsFirst degree:First degree: Injury to perineal skin onlySecond degree:Second degree: Injury to perineum involving perineal

muscles but not involving the anal sphincter

Third degree:Third degree: Injury to perineum involving the anal sphincter complex:

3a:3a: Less than 50% of EAS thickness torn.3b:3b: More than 50% of EAS thickness torn.3c: 3c: Both EAS and IAS torn.

Fourth degree:Fourth degree: Injury to perineum involving the anal sphincter complex (EAS and IAS) and

anal epithelium.ICI & RCOG

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““New insights into the pathophysiology and New insights into the pathophysiology and management of patients with faecal management of patients with faecal incontinence have been gained in the past incontinence have been gained in the past three years, largely as a result of new three years, largely as a result of new

ways of imaging anal sphincters, …….”ways of imaging anal sphincters, …….”

ENDOANAL ULTRASOUND

MA Kamm, The Lancet 1994MA Kamm, The Lancet 1994

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ENDOANAL ULTRASOUNDTechnical aspect

Mechanical Transducer Mechanical Transducer Rotating Scanning: full 360° Rotating Scanning: full 360° Frequency Range: 5 - 10 MHzFrequency Range: 5 - 10 MHz

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Sultan et al Clinical Radiology 1994;49:368-374

Valutazione ecografica Endoanale

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Ecografia EndoanaleImmagine ecografica: SAE e SAI

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Ecografia endoanale 3- D Aspetti tecnici

Mechanical Transducer Rotating Scanning: full 360° Frequency Range 6 - 16 MHz

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Ecografia endoanale 3- D

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EndoAnal US in 202 consecutive pregnant womenEndoAnal US in 202 consecutive pregnant womenBefore, 6 week and 6 months after deliveryBefore, 6 week and 6 months after delivery

“Anal sphincter disruption during Vaginal delivery”

Symptoms after delivery Endoanal US findingsAI/Urgency before delivery after delivery

Nulliparae 13% 0 35%

Multiparae 23% 40% 44%

Strong association (p<0.001) between either symptom and sphincter defects

A. Sultan et al. A. Sultan et al. N Engl J MedN Engl J Med 1993 1993

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Difetto SAE e SAI

M.A. Kamm Lancet 1994;344:730-33

Ecografia endoanale

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28% out of 150 Nulliparous women28% out of 150 Nulliparous women

“Occult Anal sphincter defects on EndoAnal US after vaginal delivery”

Faltin et al. Faltin et al. Obstet Gynecol 2000Obstet Gynecol 2000

33.5% out of 197 Nulliparous women33.5% out of 197 Nulliparous womenDamon et al. Damon et al. Dis Colon Rectum 2005Dis Colon Rectum 2005

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On multivariate analysis only sphincter defect on EndoAnal US after Ist delivery was significantly associated with AI 6 years later (o.r. 10.5; 95% CI, 2.1-52.4)

Damon et al, 2005

Long term consequences of occult anal sphincter defect

Anal Incontinence 6 years after the index vaginal delivery in 54 women

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EPISIOTOMIAM

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22 articles, 651.934 women includedEpisiotomy & Severe perineal tears

(OR 3.69 [95% CI, 1.45–9.38; P < 0.001])

• Median episiotomy (OR 3.82 [95% CI, 1.96–7.42]; P < 0.001)

• Mediolateral episiotomy (OR 1.72 [95% CI, 0.81–3.65]; P = 0.16)

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“Risk Factors for Obstetric Anal Risk Factors for Obstetric Anal Sphincter Injury: a prospective study”Sphincter Injury: a prospective study”

Standard mediolateral episiotomyat least 40° from the midline

Andrews et al 2006

““only 13% intended mediolateral only 13% intended mediolateral episiotomies in our study were, by episiotomies in our study were, by

definition, genuinely definition, genuinely mediolateral”mediolateral”

Angle of episiotomy 26° (13)Angle of episiotomy 26° (13) 37° (16) 37° (16) mean (SD)mean (SD)

α

Anal canal

episiotomy

Vagina

OASISOASIS No OASISNo OASIS

P = 0.01P = 0.01

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Mediolateral episiotomyMediolateral episiotomy

Eogan et al 2006

The role of the Angle on OASISThe role of the Angle on OASIS

• Angle of episiotomy Angle of episiotomy (mean)(mean)

54 Cases 54 Cases 46 Controls 46 Controls (OASIS)(OASIS) vsvs (No OASIS) (No OASIS)

30° 30° (95%, 28-32)(95%, 28-32)

38° 38° (95%, 35-41)(95%, 35-41)

50% relative reduction risk for ever 6 ° away from perineal midline

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• Che fare?Che fare?

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“Occult anal sphincter injuries (OASIS):

myth or reality?”

254 primipare

Esame obiettivo immediato postpartumOstetrica/Medico

Ecografia EA e Riparazione delle lesioni identificate Aiuto esperto

Andrews et al, 2006

MetodiMetodi

Rivalutazione immediataRicercatore espertoM

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“Occult anal sphincter injuries: myth or reality?”

Andrews et al, 2006

RisultatiRisultati Lesioni Sfinteriche Ostetriche

• Esame obiettivo immediato postpartumOstetrica/Medico

• Ecografia EA e Riparazione delle lesioni identificate Aiuto esperto

• Rivalutazione immediataRicercatore esperto

11%

24.5%

+ 1.2%

(lesioni misconosciute: 87% / 28%)

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“Risk Factors for Obstetric Anal Sphincter Risk Factors for Obstetric Anal Sphincter Injury: a prospective study”Injury: a prospective study”

241 nulliparous women included25% sphincter injuries

Andrews et al 2006

Univariate analysisUnivariate analysis

• Forceps delivery• Vacuum extraction• Gestation > 40 weeks• Mediolateral episiotomy• Higher birthweight• Larger head circumference• Longer IInd stage of labour

Independent Risk Factors Independent Risk Factors at multiple logistic at multiple logistic regression analysisregression analysis

• Higher birthweight

• Mediolateral episiotomy

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“Risk Factors for Obstetric Anal Risk Factors for Obstetric Anal Sphincter Injury: a prospective study”Sphincter Injury: a prospective study”

241 nulliparous women includedData re-analyzed on the basis of Accoucheur’s diagnosis

11% sphincter injuries

Andrews et al 2006

Univariate analysisUnivariate analysis

• Forceps delivery• Vacuum extraction• Gestation > 40 weeks• Mediolateral episiotomy• Higher birthweight• Larger head circumference• Longer IInd stage of labour

Independent Risk Factors Independent Risk Factors at multiple logistic at multiple logistic regression analysisregression analysis

• Forceps delivery

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Fattori di Rischio per lesioni Ostetriche perinealiFattori di Rischio per lesioni Ostetriche perineali

Andrews et al 2006

Aspetti criticiAspetti critici

• Studi prospettici con più accurata definizione sia dei

fattori di rischio analizzati che degli outcomes misurati

Ricerca

Clinica

• Rivalutazione delle modalità di esecuzione

dell’episiotomia mediolaterale

• Maggiore accuratezza nella valutazione clinica del

perineo nell’immediato post-partum

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Repair of OASIGUIDELINESGUIDELINES

1. Performed by an experienced operator2. Operating theatre3. GA or Spinal4. Grade injury5. Anal epithelium repaired with Vicryl 3/0 or Vicryl rapide6. IAS end to end7. EAS – end to end or overlap – 2.0 PDS8. Routine perineal repair

Andrews, Sultan and Thakar. Reviews in Gynaecological Practice

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GUIDELINESGUIDELINES9. Rectovaginal exam

10. IV antibiotics

11. Foley catheter – 24 hrs

12. Detailed notes

13. Laxatives

EXPLAIN & DEBRIEFEXPLAIN & DEBRIEFAndrews, Sultan and Thakar. Reviews in Gynaecological Practice.

Repair of OASIEvento Ostetrico e Perineo


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Technique of of anal sphincter closureTechnique of of anal sphincter closure

OverlapOverlap

End-to-end End-to-end


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12 months < risk of faecal urgency &Anal Incontinence

36 months no differences


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Overlap vs End-to-end:

Role of Perineal Clinic

• All women who have had obstetric anal sphincter repair should be reviewed 6 –12 weeks postpartum by a consultant obstetrician and gynaecologist

• All women should be offered physiotherapy and pelvic-floor exercises for 6 –12 weeks after obstetric anal sphincter repair.

RCOG guidelines March 2007


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GrazieGrazie


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Evento Ostetrico e Perineo Le lacerazioni perineali

Health & Medicine

Transcript of Evento Ostetrico e Perineo Le lacerazioni perineali